Nepali Times
A nation's health

There used to be a time when Nepal's health statistics were the worst in the world. The country's maternal and child mortality figures were off the charts, and worse than many countries in sub-Saharan Africa.

Nearly 1,000 mothers out of every 100,000 died at child-birth because the simplest delivery techniques and knowledge were not available with rural midwives, or remote area health posts. Child marriage was so common that many mothers gave birth at 15, were severely anemic, under-nourished and over-worked.

Children died of simple infections and vaccine-preventable diseases. Diarrohoeal dehydration and acute respiratory infections meant that one in every five children did not live to be five years old. Three-fourths of all children were undernourished.

Things have improved dramatically in the last 20 years. Thanks largely to higher literacy, especially among girls, the average age of marriage has been pushed back. Nutrition levels have improved with greater awareness. Tens of thousands of Female Community Health Volunteers scattered across rural Nepal have done more for the improvement in maternal and child survival than anyone else. The spread of roads has meant that mothers with delivery complications can now be rushed to hospitals.

This is not to say that we can now sit back and relax. There has been a worrying plateauing off in the past two years of female literacy, and as a consequence mother-child survival rates have stagnated. The cholera epidemic in Doti this month has shown that we haven't learnt a thing from the Jajarkot outbreak two years ago that killed nearly 400 people, mainly children. Half of Nepal's children still go to bed hungry every night, they are vulnerable to opportunistic infections. Water-borne diseases are still major killers, so new safe drinking water systems are needed, existing ones must be properly maintained. Climate variability and chronic drought is lowering the water table, water sources are contaminated.

As we have often argued, these are not health problems but an outcome of political neglect and apathy. Most politicians, legislators and civil servants are so engrossed in their power games and purloining the allocations to VDCs and DDCs that couldn't care less if there is a cholera outbreak in their district. Vaccination campaigns for polio and Vitamin A are disturbed by political shutdowns and strikes, with devastating consequences on public health.

Despite all this, as other countries have before us, Nepal is moving from a phase when public health was mainly concerned with prevention of infections to one where cure is becoming increasingly important. Even though 1,500 new doctors graduate from private and government medical schools every year, Nepal has only two doctors for every 10,000 population: the lowest rate in Asia.

Most of those doctors do not want to serve in rural areas, and either migrate to the cities or move abroad where they can earn more. In many districts like Mugu, the hospital is just a building with no equipment and no staff. Retention of medical personnel in rural hospitals has now become a major crisis. Highway accidents have become the main killers of young adults in the country, but most district hospitals have unserviceable x-ray machines and operation theatres. Private hospitals are out of reach of a majority of the population, and there is a crying need for a national health insurance system.

Fortunately, there are now hospitals like the one in Bayalpata in Achham, and a new social audit of rural health care that gives local communities a voice in demanding better services. There are medical schools like the Patan Academy of Health Sciences which are working to motivate graduates to serve in rural hospitals. A study by the Kathmandu-based Nick Simons Institute published this week in the British Medical Journal, and also featured in this issue, tracks down graduates from the Institute of Medicine over the past 22 years to look for factors that increase the likelihood of graduates serving in district hospitals.

The study shows that selecting medical school applicants who have a rural birthplace, have studied in the districts and have worked their way up as paramedics, improves the likelihood of the doctors serving in rural Nepal after graduation.

Nepal's public health crisis is far from over. Preventing infections through awareness, safe drinking water, reducing indoor pollution and vaccination campaigns should still be top priority. But it is also necessary to ensure that rural hospitals have trained medical staff at all times.

Read also:
Why some doctors stay and others go away, KUNDA DIXIT
New study finds factors that make Nepali doctors more likely to practice in rural Nepal instead of moving to Kathmandu or migrating abroad

In an ailing state, ANURAG ACHARYA
If this is the state of city hospitals, imagine what it is like in rural areas

Public participation in public health, BHRIKUTI RAI
Communities in western Nepal act to improve local governance and healthcare

1. Thomas

Case in point - the hospital in Tansen.  Out of all the staff, there are only two Nepali doctors, the rest are foreign volunteers.  The foreign volunteer doctors, who are Christians doing charity work, brings up the topic of the possible role of charity in medical care in Nepal.  The majority of hospitals in the western world were initially established by religious or civic charitable organizations.  They provided medical care for the poorest members of society, and raised the money to provide that care, and only gradually shifted to insurance-based funding.  Even today, a large percentage of hospitals are non-profits run by charitable groups. Even in countries without national health insurance, all hospitals, (non-profits, for-profit, and public), provide emergency care to patients who don't have insurance and can't pay, so there is an element of charity throughout the system.

What could the role of charitable organizations in Nepal be in providing care to rural areas and to the poor?  Government-mandated or funded national health insurance would probably provide improved care if it were implemented in Nepal, as would increased spending on rural clinics and hospitals, but charities constructed literally thousands of hospitals in the West (and many in India) long before government came to dominate the healthcare field.

2. Krishna S.
Such an insightful article. Too bad the usual 89 comments that follows an editorial that mentions Prachanda or constitution or India are missing!

Have you seen living conditions in Mugu? You would have to be more altruistic than Mahatma Gandhi to give up a medical career in the west to pursue your inner calling and have adventures in those remote places.

I do not blame Nepali Medical Professionals. We can preach "Holier than thou" attitude to others, but to afford it is an entirely different thing. 

(11 JAN 2013 - 17 JAN 2013)